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Carpal Tunnel Syndrome

Updated on April 13, 2018
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Kortney has been a clinical physician assistant for 13 yrs. When not being a PA, Kortney’s hobbies include writing, research, and investing.

A little about me...

I am an orthopedic physician assistant. I have been working in occupational medicine for the last 13 years and primarily work with orthopedic type injuries. Carpal Tunnel Syndrome (CTS) is one of the most common orthopedic problems that I see in practicing occupational medicine. This article address the common symptoms, findings, and treatments.


I also complete peer reviews for the worker's compensation system. In my peer reviews, I reference up to date, relevant research on many topics, including carpal tunnel syndrome. I frequently reference the Official Disability Guidelines (ODG), which is a database of evidence based literature and treatment recommendations for primarily occupational injuries and patients with disabilities. These guidelines are developed by the Work Loss Data Institute and are regularly updated to reflect the most recent research. ODG can only be accessed via a paid membership, which can be expensive. I have access to these guidelines for my job and consider them to be an invaluable resource.

Causes of Carpal Tunnel Syndrome

Carpal tunnel syndrome is a relatively common condition among workers who frequently use the computer for typing, mousing, and for repetitively writing. This condition typically results from repetitive overuse of the hands and wrists among workers who perform fine motor tasks, such as typing and writing. This condition is characterized by numbness and pain in the wrist and hand. The median nerve travels through a small tunnel in your wrist and with repetitive use of the wrist and hand, there can be swelling and micro-trauma in this area, causing compression of the median nerve. This syndrome is also referred to as median neuritis, which basically means that the median nerve in the wrist is compressed or irritated.

Carpal tunnel syndrome can also be caused by an acute trauma to the wrist and hands, such as in a car accident when a driver is gripping the steering wheel. It is more commonly caused by repetitive activity, but could also be caused by one acute, or several smaller traumas to the wrist. Any repetitive gripping activity can also result in the development of median neuritis, as well.

There are also medical conditions that predispose a person to developing carpal tunnel syndrome. Patients with diabetes are more likely to develop median neuritis due to swelling in arms and legs. Extra fluid in the wrists can cause compression of the median nerve. This also occurs in persons who are pregnant, when extra swelling is more common. People with thyroid disorders are also more prone to developing this condition.

In carpal tunnel syndrome, the median nerve gets compressed in the carpal canal. As seen in the diagram below, the median nerve innervates the thumb, index fing

How this is diagnosed...

Carpal tunnel syndrome is a commonly diagnosed based on clinical assessment. The typical signs and symptoms of carpal tunnel syndrome include pain, numbness, and tingling in the thumb, index finger, and middle finger in the hand and pain in the wrist. A patient presenting with pain and numbness in this type of distribution is suspected of having this diagnosis. A physical examination can also identify sensory or motor changes in the same distribution of the median nerve.

There are orthopedic tests that help in identifying this condition, as well, including a Tinel's and Phalen's sign. A Phalen's sign is an objective test during which the patient is asked to bend the wrists and press the backs of the hands against each other for a period of about 5-20 seconds. A person who has carpal tunnel syndrome or median neuritis will develop symptoms of tingling in the distribution of the median nerve (thumb, index finger, and middle finger) with this type of test. A Tinel's sign is a test during which the physician or medical practitioner pinpoints the median nerve at the wrist with a series of brisk tapping motions on the median nerve. A positive Tinel's sign is when this type of motion causes pain and tingling in the distribution of the median nerve. The exam will also focus on determining if there is any weakness in the thenar muscle of your hand, which is the muscle just below your thumb on the palmer side of the hand.

If a person is suspected of having this diagnosis, a physician or medical practitioner will typically refer the person for diagnostic testing. The most common diagnostic test used to identify this condition is called electrodiagnostic testing (EMG/NCV). During electrodiagnostic testing, the nerves and muscles in the arms are stimulated to determine if there is a normal response to the stimulation. On this type of testing, a needle is inserted into the muscles in the arms and wrists to determine if the muscles are being stimulated by the nerves appropriately. Patients who have carpal tunnel syndrome will have what is called "slowing" of the median nerve, which literally means that the median nerve is compressed or pathological, causing it to be slow in response to stimuli.

A positive electrodiagnostic result will confirm the diagnosis of carpal tunnel syndrome. However, some patients have clinical examination findings suggestive of CTS and do not have positive findings on electrodiagnostic testing, but this is a relatively small portion of the population.

A video showing anatomy of carpal tunnel syndrome

Treatment

There are many different types of treatment for this diagnosis. Although surgery is an option, many doctors will recommend that you undergo a series of non-operative treatments first. Typically, most people will have either complete resolution or partial relief with non-operative treatments. Sometimes, surgery can be completely avoided by following a regimen of exercise, bracing, and activity modification.


MEDICATIONS:

There are some medications that are typically used in the treatment of carpal tunnel syndrome. The most commonly used medication in most orthopedic diagnoses is a nonsteroidal anti-inflammatory medication (NSAID). A common NSAID used is ibuprofen or Motrin. In a person who presents with signs and symptoms of carpal tunnel syndrome, a practitioner will typically recommend that they start a nonsteroidal anti-inflammatory medication, such as ibuprofen. This medication can help to decrease the inflammation in the wrist, relieving the pressure on the median nerve.

Another medication would include a neuropathic pain medication. There are many types of neuropathic pain medications, including tricyclic/SNRI antidepressants and/or anticonvulsants, such as Lyrica and gabapentin. The Official Disability Guidelines recommend the use of neuropathic pain medications as a first line treatment for neuropathic pain, such as carpal tunnel syndrome (CTS). CTS is characterized by neuropathic pain because compression of the median nerve is what causes the symptoms in this diagnosis. Neuropathic pain medications can help to decrease the symptoms of neuritis associated with this syndrome. However, this is not considered to be a definitive treatment, as a patient would need to continue on neuropathic pain medications for an extended duration, as discontinuation of these medications would typically result in recurrence of symptoms.


PHYSICAL THERAPY

A practitioner will initially recommend a course of physical therapy/exercise. The Official Disability Guidelines (ODG) recommend consideration for a course of physical therapy as an initial treatment for this condition. However, current evidence based literature recommends a very limited course of physical therapy to include 1-3 sessions only. Physical therapy will focus on the use of topical treatments and therapeutic exercises to treat this condition. Topical treatments would include electrical stimulation, heat, cold, and therapeutic ultrasound. At the conclusion of the 3 sessions of physical therapy, a person will be discharged to an independent exercise program. A practitioner will typically recommend that a person regularly participate in an exercise program at home for this condition. The physical therapist will have taught exercises that the patient can continue at home as an extension of the treatment process.


BRACING/SPLINTING

Another relatively effective treatment for carpal tunnel syndrome is the use of a wrist splint. The theory is that a wrist splint will help to decrease the repetitive stress on the wrist, ultimately leading to decreased inflammation and compression of the median nerve. Most patients who present with signs and symptoms of carpal tunnel syndrome will be given a wrist splint. The Official Disability Guidelines recommend the use of a wrist splint as an initial part of treatment for patients with carpal tunnel syndrome.


INJECTIONS

A diagnostic/therapeutic corticosteroid injection is also recommended as part of the non-operative treatment. In fact, the Official Disability Guidelines recommend that an injection be administered before surgery is even considered. The injection is administered into the carpal tunnel region around the median nerve with the goal of decreasing inflammation around the nerve, relieving the pressure. A steroid and a local anesthetic are used for these injections. The local anesthetic will relief pain for a short duration, but the steroid can relieve inflammation over the long term, relieving the compression on the median nerve. This injection can be considered diagnostic, as patients who have a positive response to the injection with decreased pain and decreased neuropathic symptoms can be confirmed to have this diagnosis and it is expected that patients who have a positive response to the injection will also have a positive response to decompressive surgery. However, a carpal tunnel injection is commonly only able to provide very short term relief for up to a few weeks or a month. It is relatively rare that an injection will provide long term relief.

For Research Purposes - please answer...

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Surgery

If conservative/non-operative treatment fails to provide long term benefit and the patient continues with symptoms and signs of this condition, surgery is recommended. The Official Disability Guidelines recommend that surgery be used as part of the initial treatment in patients who have severe carpal tunnel syndrome with thenar muscle atrophy. However, in patients with mild or moderate carpal tunnel syndrome, non-operative care is recommended before surgery is considered. Surgery usually involves relieving the pressure on the median nerve in the carpal tunnel. It is commonly referred to as carpal tunnel release, which literally means relieving the pressure by releasing the carpal tunnel ligament and decompressing the space around the median nerve.

In over 90% of patients with carpal tunnel syndrome, surgery is largely effective in treating this condition. It is very rare that a patient will have persistent or recurrent carpal tunnel syndrome, as surgical release of the carpal tunnel is generally only necessary on a one-time basis.

During carpal tunnel release surgery, the surgeon cuts a portion of the transverse carpal ligament that forms the roof of the carpal tunnel. A cut/incision in t

Summary

Symptoms: In the thumb, index finger, and middle finger of the hand -

  • Pain
  • Numbness
  • Tingling
  • Pins and Needles Sensation

Treatment:

  • Medications - NSAIDs (ibuprofen), neuropathic pain medications (Lyrica, gabapentin)
  • Physical Therapy/Exercise
  • Splinting/bracing
  • Injections
  • Surgery

© 2015 Kortney Tholen

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